Please describe the allergies listed above and the reaction seen with each allergy.

Restrictions
*

I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the restrictions or adaptations listed in the next question.

List restrictions or adaptations here:

List medications that are taken regularly & the dispensing directions (MUST be brought to camp in original container ONLY).

List medications that are taken during the school year that the camper does not take during the summer.

Current infectious diseases or conditions (or write "None")
*

Are all immunizations up to date?
*

Yes No

Please send an immunization record for your child to camp or check the box below acknowledging your acceptance of the risks associated not being fully immunized.
*

I am sending in (or bringing to camp on the first day) a complete immunization record. Yes, I understand the risks of not being fully immunized.

General & Emotional Health History: Check the box next to the following questions if the answer is yes. Explain each "Yes" answer in the next question.

Any recent illness or infectious disease? Any chronic or recurring illness? Any problems falling asleep / sleepwalking? Had mononucleosis (mono) in the past 12 months? If female, any abnormal menstrual history? Passed out or experienced chest pains during exercise? Any medical dietary restrictions? Wear glasses, contacts, or protective eye wear? Ever had frequent ear infections? Fainting or dizziness? Problems with joints(e.g. knees, ankles)? Skin problems (e.g. itching, rash, acne)? Ever been diagnosed with a heart murmur? Problems with diarrhea/constipation? Have asthma and/or shortness of breath? Traveled out of the country in the past 9 months? Significant event that is affecting the camper's life? (abuse, death in family, adoption, foster care, new sibling, etc.) Had a recent injury? Ever had dental problems? Have diabetes? Have a history of bedwetting? Ever been hospitalized? Ever had surgery? Ever had a head injury? Ever had seizures? Ever had high blood pressure? Ever had back problems? Have frequent headaches? Ever had an eating disorder? Ever been knocked unconscious? Emotional difficulties for which professional help was sought? Treated for ADD or ADHD?

Describe any "Yes" answers from the previous question.

Other medical conditions or diagnoses?

Check next to the medicines that should NOT be used with your child. The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Remember, put a check mark next to the items that should NOT be given.

I understand that there will be physical activities of which my child may participate and that my child may be exposed to the possibility of injury. I hereby expressly waive any and all liabilities on the part of Detroit Rescue Mission Ministries (DRMM) and their staff for any such injury. I give permission for routine medical treatment to be administered to my child. In case of an emergency, and I cannot be contacted, I give permission for DRMM staff to select a licensed physician and authorize the physician to secure proper treatment for my child. I understand that I am financially responsible for all health care related expenses for my child. I understand that photographs and / or videos may be taken of my child while at camp. I hereby give my permission for my child to be photographed or videoed and for such to be used in DRMM, American Camp Association and/or Christian Camp and Conference Association literature, videos, website, or outside advertisement and marketing. Ages of camps are inclusive. Older campers may NOT attend a younger camp. All camps are co-ed. Wildwood Ranch will not discriminate against any individual or group because of race, gender, religion, age, national origin, color, marital status, handicap or political beliefs. When your application and deposit are received, a medical form and confirmation letter will be sent to you explaining camp procedures, spending money and a suggested list of needed articles for your stay at Wildwood Ranch.
*